Transcript BASA-slidesOBSERVATIONx

The Two Midnight Rule,
Skilled Nursing Facility Rules
and How “The Rules” Impact Patients
Information for the Community
The Rule Makers
Centers for Medicare and Medicaid Services
• The Centers for Medicare & Medicaid Services (CMS), is a
federal agency within the US Department of Health &
Human Services that:
- administers the Medicare program
- works with state governments to administer Medicaid and
the State Children's Health Insurance Program (SCHIP)
- Oversees healthcare.gov website
The New Rules
Who is affected?
• The rules affect patients with coverage through
Medicare and some Medicare Advantage plans
• The rule also impacts hospitals who accept Medicare
- CMS pays hospitals for the care delivered to those covered
by Medicare
- Hospitals are required to comply
The 2 Midnight Rule
Inpatient Admission
• On October 1, 2013, CMS implemented a new rule for
who can be admitted to the hospital as an inpatient
- Essentially, their definition of “inpatient” changed
• Old Definition: An inpatient is a patient in the hospital
for more than 24 hours
• New Definition: An inpatient is a patient
requiring a hospitalization encompassing
two midnights and supported by medical
necessity
Service covered under Medicare Part B
Services covered under Medicare Part B
• Medicare pays 80% of their approved rate
• Once the $147 Part B deductible is met, the 20%
balance is either paid by the patient or paid by
the patient’s supplemental coverage if they have
one.
• if person has a Medicare Advantage Plan, that
plan will pay based on their specific contract.
Services covered under Medicare Part A
• The patient is responsible for the deductible of
$1,216
• Part A covers:
-
semi-private room & board
Nursing services
Other hospital services & supplies which include
medications
• Some physician’s services and tests may be
covered under Medicare Part B
• First 60 days – Medicare pays all except for the
$1,216 deductible
• Days 61 to 90 – Medicare pays all except $304
per day.
• Days 91 to 150 – Medicare pays all except $608
per day.
• Above 150 days – Medicare pays nothing
• The deductible must be paid when a readmittance occurs after each 60 day period
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The $1,216 deductible is paid by the patient or
supplemental insurance product, if they have one.
If the hospital stay exceeds 60 days, daily co-pays
are either paid by the patient or by their
supplement insurance product, if they have one.
If the patient has one of the many Medicare
Advantage Plans, there is usually a sizable initial
co-pay that is the responsibility of the patient.
• Medicare pays differently for observation stays as opposed to inpatient
stays even if the same bed and room are used.
• Observation status is always covered under Medicare Part B, as an
outpatient service.
• Medicare pays 80% of the approved amount and the patient pays the
remaining 20% after the $147 Part B deductible is met.
• If a patient has one of the Medicare Advantage Plans, generally co-pays,
and expenses are paid according to the plan’s benefits.
• Medications that are furnished under observation are considered selfadministered even if given under the supervision of a nurse.
The 2 Midnight Rule
Inpatient Admission
• Patients with an expected length of stay not spanning
two midnights do not qualify as inpatients and are not
eligible for payment under Medicare Part A.
- This is true for both medical and surgical cases
- There are some exceptions for surgeries/procedures on
Medicare’s “INPATIENT ONLY”. In these cases, the length of
stay does not matter.
Skilled Nursing Facility Rule
3 Night Inpatient Stay Requirement
• The required 3 night inpatient stay to qualify for Skilled
Nursing Facility (SNF) coverage has not changed.
• Patients must have three days as an inpatient qualify for
Medicare coverage
• Nights spent in “Observation” DO NOT COUNT toward
the 3-night inpatient stay
 Medicare pays for the first 20 days of nursing home care
if followed by 3 full days of an inpatient hospital stay.
Skilled Nursing Facility Rule
3 Night Inpatient Stay Requirement
• Requirements to qualify for Medicare coverage at a
qualified Skilled Nursing Facility at discharge
- Patient must have spent 3 nights as an inpatient at the
hospital meeting medical necessity requirement
- Coverage is not based on patient, hospital, or family worry
or inconvenience, social reasons or financial need
- Medicare Advantage plans have different
rules
Care Coordination
What Munson is Doing
• Performing a needs assessment shortly after admission
or, if a planned procedure, having a discussion prior to
admission
• Care team collaborates to meet patient needs but must
follow your insurance regulations and mandates
• A case manager will discuss options with you regarding
home care services, skilled nursing facility services, and
availability of other community resources
Medicare Processes
How You Are Notified
• Medicare requires patients to sign an informational
sheet when admitted to the hospital and again prior to
discharge depending on how long you are in the hospital
• On the back of this form is how to dispute or disagree
with your discharge
Medicare Processes
Disputed Discharge - Know Your Rights
• DOES NOT give you a qualifying stay in a skilled nursing
facility unless Medicare rules in your favor
• You do not have to pay extra for your stay during the
disputed time (will be responsible for co-pays and
deductibles you would have incurred if not ready for
discharge)
Patient Out-of-Pocket
Outpatient or Observation Care
• Outpatient/Observation status patients receive a letter
explaining out-of-pocket expenses, and how to get
medications reimbursed
- Concerns about “self administered/home medications”
- Financial Counselors can help explain your insurance benefit
• Inpatients have a deductible and co-pay
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If a Medicare beneficiary has a
supplemental/medigap plan, co-pays and
deductibles may be covered. Each plan pays
differently so it is important to know your plan.
Supplemental plans may pay for both the Part A and
Part B deductibles and the associated 20% co-pays
not paid by Medicare.
Even if the observation patient has supplemental
insurance, they will still need to seek
reimbursement from their prescription drug
insurance and most likely have a higher co-pay than
normal.
Resources
Where to Go for Information
• Medicare Website - www.medicare.gov
• Medicare Publications
- Are you a Hospital Inpatient or Outpatient?
- How Medicare covers self-administered drugs given in
Hospital outpatient settings
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MMAP Team Members provide individual counseling
for people who need help with all aspects of
Medicare and Medicaid benefits.
services are free.
help beneficiaries find the correct Medicare plans
and often save them money in the process.
A good online resource for Medicare information is:
www.medicare.gov
Questions
Here to Help
Linda Hansen, Manager
Utilization Management
Munson Medical Center
(231) 935-6955
[email protected]
Lise Kolinski, Manager
Social Work/Case Management
Munson Medical Center
(231) 935-6392
[email protected]